Orthop Clin N Am 38 (2007) 127–148
Wrist Anatomy and Surgical Approaches
Roy Cardoso, MD, Robert M. Szabo, MD, MPH*
Department of Orthopaedic Surgery, University of California, Davis, School of Medicine, 4860 Y Street,
Suite 3800, Sacramento, CA 95817, USA
Appreciation and knowledge of anatomy as it
relates to surgical approaches is critical for
planning treatment of traumatic wrist injuries.
This article discusses the pertinent anatomy and
some of the more commonly used approaches to
wrist trauma.
Surface landmarks
Important dorsal landmarks include the
styloid process of the long-finger metacarpal,
anatomic snuffbox, Lister’s tubercle, lunate fossa,
the radial styloid, and the head of the ulna
(Fig. 1).
The anatomic snuffbox is formed by the third
dorsal compartment (extensor pollicis longus)
ulnarly, the first dorsal compartment (abductor
pollicis longus, extensor pollicis brevis) radially,
and the extensor retinaculum proximally. Its
contents include the dorsal continuation of the
radial artery and branches of the radial sensory
nerve.
Lister’s tubercle, a dorsal prominence over the
distal aspect of the radius, redirects the extensor
pollicis longus, which lies just ulnar to it, ap-
proximately 0.5 cm proximal to the radio-
carpal joint [1]. The lunate fossa is a palpable
depression found in line with the third metacar-
pal. The lunate bone lies directly below this
depression.
Important landmarks on the palm and volar
aspect of the wrist are illustrated in Fig. 2. Kaplan
described his cardinal line in 1953 [2]. As a surface
marker, this line helps localize deeper structures
* Corresponding author.
E-mail address: rmszabo@ucdavis.edu
(R.M. Szabo).
0030-5898/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.ocl.2007.02.010
in the hand and wrist. Although experts dis-
agree on the exact manner in which the line is
drawn and its relationship to deeper structures,
it continues to be an important and widely used
tool [3].
Kaplan’s line is made by extending a transverse
line across the palm, in line with the distal aspect
of the thumb metacarpal. Additionally, longitu-
dinal lines are drawn perpendicular to Kaplan’s
line, along the radial aspect of long finger and the
ulnar aspect of the ring finger. The intersecting
lines form a grid whose points demarcate
underlying neurovascular structures (Fig. 3).
Osteology and joint anatomy
The skeletal components of the wrist include
the distal radius and ulna, eight carpal bones,
and the proximal ends of the five metacarpals
(Fig. 4). The articular surface of the distal radius
is typically tilted with 22 of radial inclination, 11
of volar tilt, and 12 mm of radial height (Fig. 5).
Its articulation is composed of two fossaed
the ovoid-shaped lunate fossa and triangular
scaphoid fossadwhich articulate with the lunate
and scaphoid bones, respectively (Fig. 6). The
radiocarpal joint allows multiple axes of motion,
including flexion, extension, radial deviation,
and ulnar deviation [4]. On the ulnar aspect of
the distal radius, the sigmoid notch articulates
with the distal ulna to form the distal radioulnar
joint (DRUJ). The DRUJ, a pivot joint, permits
pronation and supination of the wrist. Although
the arc of curvature of the sigmoid notch varies,
it is typically greater than that of the ulnar
head. This incongruity permits both translation
and rotation of the DRUJ. Consequently, the
ulna translates dorsally in pronation and volarly
orthopedic.theclinics.com
128 CARDOSO & SZABO
Fig. 1. Dorsal wrist landmarks. (Reproduced from Doyle
JR, Botte MJ. Surgical anatomy of the hand and upper
extremity. Philadelphia: Lippincott Williams and
Wilkins; 2003. p. 486–529; with permission.)
in supination. Although the joint is primarily sta-
bilized by the triangular fibrocartilage complex
(TFCC), additional stability is imparted by the
joint capsule, interosseous membrane, pronator
quadratus, and extensor carpi ulnaris [5].
Fig. 2. Palmar wrist landmarks. (From Trumble TE. Principles of hand surgery and therapy. Philadelphia: W.B. Saun-
ders; 2000. p. 1–18; with permission.)
The distal ulna does not typically articulate
with the carpus. Its distal surface, covered by the
triangular fibrocartilage (TFC), is composed of
the head, seat, styloid, and fovea. The carpal
bones are arranged into a proximal and distal
row. The midcarpal joint is the articulation
between the rows. The proximal row, formed by
the scaphoid, lunate, and triquetrum, has no
muscular attachments; it articulates with the
trapezium, trapezoid, capitate, and hamate. The
scaphoid occupies both rows. The eighth carpal
bone, the pisiform, is a sesamoid bone of the
flexor carpi ulnaris and does not contribute to
midcarpal joint motion.
Ligament anatomy
The ligaments of the wrist have been described
and named differently by several investigators.
Taleisnik [6] groups wrist ligaments into extrinsic
and intrinsic, palmar, and dorsal. The extrinsic
ligaments span the radiocarpal and midcarpal
joints, whereas the intrinsic ligaments connect
the carpal bones.
The palmar radiocarpal ligaments are extrinsic,
originating from the palmar edge of the distal
radius and traveling toward to the scaphoid,
lunate, and capitate (Fig. 7). The radial-most
 WRIST ANATOMY AND SURGICAL APPROACHES
Fig. 3. Kaplan’s cardinal line and associated structures. (Reproduced from Carlson GC. Surgical approaches to the hand
and wrist. In: Chapman MW, editor. Chapman’s orthopaedic surgery. 3rd edition. Philadelphia: Lippincott Williams &
Wilkins; 2001. p. 1239–46; with permission.)
extrinsic ligament, the radioscaphocapitate liga-
ment (RSC), originates from the radial styloid,
travels across the waist and distal pole of the
scaphoid, crosses the capitate, and coalesces with
the ulnocapitate ligament (Fig. 8). The RSC is typ-
ically divided when performing a volar approach
Fig. 4. Osseous Anatomy of the wrist. (From Steinburg
BD, Plancher KD. Clinical anatomy of the wrist and
elbow. Clin Sports Med 1995;14(2):299–313; with
permission.)
129
to the scaphoid and should be repaired because
it is an important stabilizer of the radial wrist.
The long radiolunate ligament lies just ulnar to
the RSC and may also be encountered during
a volar approach to the scaphoid. Along with
the short radiolunate, the long radiolunate liga-
ment functions as a primary restraint to lunate
displacement with perilunate dislocations [6].
The radioscapholunate ligament, also known as
the ligament of Testut, is actually a neurovas-
cular bundle and contributes nothing to carpal
stability.
The ulnocarpal ligaments (see Figs. 8 and 9)
arise from the distal ulna and, in conjunction
with the TFC and the sheath of the extensor carpi
ulnaris, form the TFCC. The TFCC serves as the
primary stabilizer of the DRUJ [7,8]. The TFC
originates from the lunate and sigmoid fossae of
the distal radius and inserts into the base of the
ulnar styloid. Its peripheral layer is composed of
thick, well-vascularized volar and dorsal liga-
mentous bands: the dorsal and palmar radioulnar
ligaments. Between these bands, a central area of
fibrocartilage is avascular, load-bearing, and of-
ten likened to the meniscus of the knee. It arti-
culates with the distal ulna and triquetrum
(Fig. 9) [5].
130 CARDOSO & SZABO

Fig. 5. The various angles to assess in distal radius fractures. (A) Radial inclination (RI), normal, 22 . (B) Radial length
(RL), normal, 12 mm. (C) Ulnar variance (UV), normal, 0–2 mm. (D) Radial tilt (RT), normal, 11 volar. (Reproduced
from Graham TJ. Surgical correction of malunited fractures of the distal radius. J Am Acad Orthop Surg 1997;5:270–81;
with permission.)

Dorsally, the dorsal radiotriquetral (radiocar-
pal) ligament and the dorsal intercarpal ligament
help stabilize the wrist. The former helps stabilize
the lunotriquetral joint, preventing volar interca-
lated segment instability (Fig. 10). The latter is an
important stabilizer of the proximal pole of the
scaphoid. Frequently injured intercarpal liga-
ments include the scapholunate interosseous
ligament and the lunotriquetral interosseous liga-
ment. The scapholunate ligament has proximal,
dorsal, and volar components, with the dorsal
the strongest and therefore most critical joint sta-
bilizer. When torn, dorsal intercalated segment
instability can result. In contrast, the lunotrique-
tral ligament is strongest at its volar aspect. Injury
to this ligament may result in volar intercalated
segment instability [9].

Fig. 6. Articular surface of the distal radius. (From
Bowers WH. The distal radioulnar joint. In: Green
DP, Hotchkiss RN, Pederson WC, editors. Operative
hand surgery. 3rd edition. New York: Churchill Living-
stone; 1993. p. 976; with permission.)
Retinacular anatomy
Two distinct fascial layers encompass the volar
wrist. The superficial layer consists of the volar
carpal ligament and palmar fascia. A deeper
layer, the flexor retinaculum, is divided into three
 WRIST ANATOMY AND SURGICAL APPROACHES
Fig. 7. Components of the radioscaphocapitate liga-
ment. 1, radioscaphoid component; 2, radiocapitate
component. (From Weber ER. Physiologic bases for
wrist function. In: Lichtman DM, Alexander AH,
editors. The wrist and its disorders. Philadelphia: W.B.
Saunders; 1997; with permission.)
anatomic zones from proximal to distal (Fig. 11).
The proximal portion is largely contiguous with
the antebrachial fascia. The middle portion, the
transverse carpal ligament (TCL), attaches ul-
narly to the hook of the hamate and the pisiform,
and radially to the scaphoid tubercle and trape-
zial tuberosity. The TCL serves as the roof of
the carpal canal. The distal portion is the apo-
neurosis between the thenar and hypothenar
muscles.
The carpal canal lies directly under the TCL
and contains the flexor pollicis longus radially, the
median nerve volarly, and the eight tendons of the
flexor digitorum superficialis and the flexor dig-
itorum profundus. Guyon’s canal is ulnar to the
carpal canal and contains the ulnar nerve and
artery. Guyon’s canal lies above the transverse
carpal ligament, between the pisiform and hook
of the hamate. Its floor is formed by the TCL
and its roof by the volar carpal ligament and pal-
maris brevis. It is bordered radially by the hook of
the hamate and the digital flexor tendons and ul-
narly by the pisiform, flexor carpi ulnaris, and ab-
ductor digiti minimi (Fig. 12).
131
Fig. 8. The anatomy of the palmar wrist ligaments.
AIA, anterior interosseous artery; C, capitate; CH, pal-
mar capitohamate ligament; H, hamate; L, lunate; LRL,
long radiolunate ligament; P, pisiform; PRU, palmar
radioulnar ligament; PTC, palmar trapezocapitate
ligament; R, radius; RA, radial artery; RSC, radiosca-
phocapitate ligament; S, scaphoid; SC, scaphocapitate
ligament; SRL, short and radiolunate ligament; STT,
scaphotrapziotrapezoid ligament; T, triquetrum; TC, tri-
quetrocapitate ligament; Td, trapezoid; TH, triquetroha-
mate ligament; Tm, trapezium; TT, palmar
trapeziotrapezoid ligament; U, ulna; UC, ulnocapitate
ligament; UL, ulnolunate ligament; UT, ulnotriquetral
ligament. (From Berger RA. Arthroscopic anatomy of
the wrist and distal radioulnar joint. Hand Clin
1999;15:393–413; with permission.)
The extensor retinaculum lies across the
dorsum of the wrist and prevents bowstringing
of the extensor tendons. The extensor tendons of
the wrist and digits pass under the extensor
retinaculum through six discrete tunnels, or dorsal
compartments (Fig. 13). In addition to their
intended function, the dorsal compartments are
excellent landmarks for surgical approaches.
Vascular anatomy
The radial artery enters the wrist just radial to
the flexor carpi radialis. It is the most consistent
arterial supply and has seven major carpal
branches. The ulnar artery has several branches,
132 CARDOSO & SZABO
Fig. 9. The components of the triangular fibrocartilage
complex. (From Loftus JB, Palmer AK. Disorders of
the DRUJ and TFCC. In: Lichtman DM, Alexander
AH, editors. The wrist and its disorders. Philadelphia;
W.B. Saunders: 1997; with permission.)
both volar and dorsal, at the level of the wrist.
The artery travels across the radiocarpal joint just
radial to the ulnar nerve. As the nerve enters
Guyon’s canal, the ulnar artery travels distally
and radially to form the superficial palmar arch.
The anterior interosseous artery bifurcates at the
proximal border of the pronator quadratus into
dorsal and palmar branches. The dorsal branch
Fig. 10. The dorsal Intercarpal ligament and dorsal radiotriquetral ligament. (From Berger RA. Ligament anatomy. In:
Cooney WP, Linscheid RL, Dobyns JH, editors. The wrist: diagnosis and operative treatment. St. Louis (MO): Mosby;
1997; with permission.)
travels along the interosseous membrane to anas-
tomose with the three dorsal carpal arches. The
palmar branch travels deep to the pronator
quadratus to supply the palmar radiocarpal arch
and terminates at the deep palmar arch.
The radial, ulnar, and anterior interosseous
arteries coalesce to form the extraosseous blood
supply to the wrist and hand. The extra-
osseous vascular supply to the wrist is composed
of three volar and three dorsal carpal arches.
Dorsally, the radiocarpal arch lies deep in the
extensor tendons at the radiocarpal joint and
supplies the lunate and triquetrum. The intercar-
pal arch, the largest and most consistent arch,
tends to supply the distal carpal row before
anastomosing with the radiocarpal arch. Finally,
the basal metacarpal arch, the smallest and least
consistently present arch, helps supply the distal
carpal row (Fig. 14) [10]. Volarly, the palmar
radiocarpal arch runs within the wrist capsule
and supplies the volar portions of the lunate and
triquetrum. The most important of the three
arches, the deep palmar arch, is located at the
metacarpal bases. It is a continuation of the radi-
al artery and supplies the distal carpal row
through the radial and ulnar recurrent branches
(Fig. 15) [10].
 WRIST ANATOMY AND SURGICAL APPROACHES
Fig. 11. The three portions of the flexor retinaculum. A,
thenar muscles; B, hypothenar muscles; H, hamate; P,
pisiform; R, flexor carpi radialis; S, scaphoid; T, trape-
zium; U, flexor carpi ulnaris. (From Cobb TK, Dalley
BK, Posteraro RH, et al. Anatomy of the flexor retinac-
ulum. J Hand Surg [Am] 1993;18:91–9; with permission
from The American Society for Surgery of the Hand.)
Fig. 12. Guyon’s canal. Note that the ulnar artery travels
radial to the canal. (From Szabo RM. Compression neu-
ropathies. In: Green DP, Hotchkiss RN, Pederson WC,
editors. Operative hand surgery. 4th edition. New York:
Churchill Livingstone; 1999; with permission.)
133
Fig. 13. The extensor retinaculum and six dorsal com-
partments. (From Trumble TE. Principles of hand sur-
gery and therapy. Philadelphia: W.B. Saunders; 2000.
p. 1–18; with permission.)
Fig. 14. Schematic drawing of the arterial supply of the
palmar aspect of the wrist. R, radial artery; U, ulnar ar-
tery; 1, palmar branch, anterior interosseous artery; 2,
palmar radiocarpal arch; 3, palmar intercarpal arch; 4,
deep palmar arch; 5, superficial palmar arch; 6, radial re-
current artery; 7, ulnar recurrent artery; 8, medial
branch, ulnar artery; 9, branch off ulnar artery contrib-
uting to dorsal intercarpal arch. (From Gelberman RH,
Panagis JS, Taleisnik J, et al. The arterial anatomy of
the human carpus. Part I: the extraosseous vascularity.
J Hand Surg 1983;8:367–75; with permission from The
American Society for Surgery of the Hand.)
134 CARDOSO & SZABO
Fig. 15. Schematic drawing of the arterial supply of the
dorsal aspect of the wrist. R, radial artery; U, ulnar artery;
1, dorsal branch, anterior interosseous artery; 2, dorsal
radiocarpal arch; 3, branch to the dorsal ridge of the
scaphoid; 4, dorsal intercarpal arch; 5, basal metacarpal
arch; 6, medial branch of the ulnar artery. (From Gelber-
man RH, Panagis JS, Taleisnik J, et al. The arterial anat-
omy of the human carpus. Part I: the extraosseous
vascularity. J Hand Surg 1983;8:367–75; with permission
from The American Society for Surgery of the Hand.)
The scaphoid receives its blood supply from
branches of the radial artery; 80% of its blood
supply enters dorsally. A dorsal ridge at the level
of the scaphoid waist, between the radius, trape-
zoid, and trapezium, is the site of vessel entry.
Consequently, this vessel must be preserved
during a dorsal approach to the scaphoid. Fur-
thermore, blood supply to the proximal pole is
supplied by a single intraosseous vessel, making
fractures to this region prone to nonunion
(Fig. 16) [10].
Surgical approaches
Volar radial approach
Indications and landmarks
The standard volar radial approach allows the
volar surface of the distal radius to be accessed
through the interval between the flexor carpi
radialis (FCR) tendon and radial artery.
Fig. 16. Schematic drawing of the arterial supply of the
lateral aspect of the wrist. R, radial artery; U, ulnar ar-
tery; 1, superficial palmar artery; 2, palmar radiocarpal
arch; 3, dorsal radiocarpal arch; 4, branch to the scaph-
oid tubercle and trapezium; 5, branch to the dorsal ridge
of the scaphoid; 6, dorsal intercarpal arch; 7, branch to
lateral trapezium and thumb metacarpal. (From Gelber-
man RH, Panagis JS, Taleisnik J, et al. The arterial anat-
omy of the human carpus. Part I: the extraosseous
vascularity. J Hand Surg 1983;8:367–75; with permission
from The American Society for Surgery of the Hand.)
Landmarks include the FCR tendon, radial
artery, and distal wrist crease (Fig. 17).
Technique
A skin incision is made along the forearm,
starting from the distal wrist crease longitudinally
or in a zigzag fashion, overlying the FCR tendon.
After dissection through subcutaneous tissue, the
FCR tendon sheath is readily visualized. The
radial artery and its venae comitantes, which lie
immediately radial to the FCR tendon, should be
identified and tagged.
Care is taken to incise the sheath directly over
the tendon, avoiding the palmar cutaneous branch
of the median nerve (PCBMN), just ulnar to the
FCR and radial artery. The tendon is then
mobilized ulnarly to reveal the floor of the tendon
sheath and protect the median nerve and its
palmar cutaneous branch. The floor of the sheath
is incised longitudinally to expose the pronator
quadratus. More proximally, the flexor digitorum
superficialis to the index finger and the flexor
pollicus longus are encountered overlying the
pronator quadratus. The flexor digitorum super-
ficialis can be swept ulnarly and the flexor pollicis
longus is mobilized radially to better visualize the
pronator quadratus. The space between the flexor
pollicis longus and radial septum can be devel-
oped to further improve visualization. As this
space is developed, branches from the radial
 WRIST ANATOMY AND SURGICAL APPROACHES 135

Fig. 17. The volar radial approach uses the interval between the flexor carpi radialis tendon and the radial artery. The
pronator quadratus is elevated sharply, starting at its insertion on the distal radius. (Reproduced from Fernandez DL,
Jupiter JB. Fractures of the distal radius. New York: Springer; 1996. p. 67–102; with permission.)

artery are sometimes encountered and must be
cauterized to facilitate exposure. When the pro-
nator quadratus is well visualized, its radial and
distal borders are sharply released in an L-shaped
fashion. The pronator quadratus is then reflected
ulnarly to expose the volar surface of the radius.
The brachioradialis is often released from its
insertion to facilitate manipulation of fracture
fragments (Fig. 18).
Extended flexor carpi radialis approach
The extended FCR approach, popularized by
Orbay et al. [11], allows access to dorsally commi-
nuted and displaced distal radius fractures from
a volar approach. Pronating the proximal frag-
ment of the radius out of the way allows the dor-
sal aspect of the distal radius to be visualized
(Fig. 19).
Technique
The FCR approach is extended by first re-
leasing the brachioradialis from its insertion. The
brachioradialis insertion is found on the floor of
the first dorsal compartment within the radial
septum (Fig. 20). After incising the compartment
sheath, the abductor pollicis longus is retracted
radially to expose the brachioradialis insertion.
Some experts advocate releasing the brachioradia-
lis in a step-cut fashion to later facilitate its repair.
The repaired brachioradialis can subsequently be
used as an anchor-point to reattach the pronator
quadratus after hardware placement. Releasing
the brachioradialis also alleviates its deforming
force on distal radial fracture fragments, permit-
ting better fracture reduction. Next, the first dor-
sal compartment is lifted off the proximal
fragment, followed by the dorsal periosteal
attachments. Finally, the proximal radial frag-
ment is pronated out of the way to better visualize
the dorsal aspect of the fracture (Fig. 19) [11].
Volar approach to the scaphoid (Russe)
Indications and landmarks
The Russe or volar approach to the scaphoid is
ideal for screw fixation of acute, scaphoid waist
fractures and treating scaphoid nonunions with
bone grafting. Like the volar approach to the wrist,
this approach uses the FCR tendon as a landmark.
The scaphoid waist lies at the intersection of the
FCR tendon and the proximal palmar wrist crease,
at the level of the radial styloid.
Technique
A longitudinal 5-cm incision is started over the
FCR tendon centered on the proximal wrist
crease. The incision crosses the wrist crease at
a 45 angle to follow the ulnar border of the
thumb metacarpal (Fig. 21). After incising the
skin and subcutaneous tissues, care is taken to
avoid the palmar cutaneous branch of the median
136 CARDOSO & SZABO

Fig. 18. The volar radial approach is through the interval between the flexor carpi radialis (FCR) and the radial artery.
R, radius; U, ulna. (Reproduced from Trumble TE, Culp R, Hanel DP, et al. Intra-articular fractures of the distal aspect
of the radius. J Bone Joint Surg Am 1998;80:582–600; reprinted with permission from The Journal of Bone and Joint
Surgery, Inc.)

Fig. 19. The extended FCR approach allows dorsal ac-

cess to intra-articular fragments from a volar approach.
The pronated proximal radius fragment (*), dorsal die-
punch fragment (L), and volar die punch fragment (J)
are shown. (From Orbay JL. Fernandez DL. Volar fixa-
tion for dorsally displaced fractures of the distal radius:
a preliminary report. J Hand Surg [Am] 2002;27(2):205–
15; with permission from The American Society for
Surgery of the Hand.)
Fig. 20. The radial septum is a complex fascial structure
consisting of the intramuscular membrane, brachiora-
dialis insertion (*), and first extensor compartment (L).
(From Orbay JL. Fernandez DL. Volar fixation for dor-
sally displaced fractures of the distal radius: a prelimi-
nary report. J Hand Surg [Am] 2002;27(2):205–15; with
permission from The American Society for Surgery of
the Hand.)
 WRIST ANATOMY AND SURGICAL APPROACHES
nerve, ulnar to the FCR. The radial artery and its
venae comitantes, which lie immediately radial to
the FCR tendon, should be identified and tagged.
The FCR tendon sheath is incised distally and the
tendon retracted ulnarly to reveal the RSC and
long radiolunate ligaments. The RSC is incised
longitudinally with the intention to repair later.
The palmar branch of the radial artery is typically
found at this level and may be ligated for better
exposure, if necessary. The capsule is then visual-
ized and incised in a longitudinal fashion. Further
exposure can also be gained by mobilizing the the-
nar muscles radially. To visualize the joint surface
of the distal pole, a capsulotomy is performed at
the scaphotrapezial joint. The wrist is then flexed
and ulnarly deviated to better view the scaphoid
(Fig. 22).
Carpal tunnel approach
Indications and landmarks
The carpal tunnel approach provides access to
the carpal canal and its contents and limited
access to the mid-carpus and the hook of the
hamate. Landmarks include Kaplan’s line, the
Fig. 21. Skin incision for volar approach to the scaph-
oid. (From Ruby LK. Arthrotomy. In: Cooney WP,
Linscheid RL, Dobyns JH, editors. The wrist: diagnosis
and operative treatment. St. Louis (MO): Mosby; 1997;
with permission.)
137
pisiform, the hook of the hamate, the thenar and
hypothenar eminences, the distal wrist crease, the
FCR, and the palmaris longus (when present).
Although no true neurovascular plane exists,
small palmar cutaneous branches of the median
nerve and branches of the ulnar cutaneous nerves
should be avoided if possible.
Nonunions of the hook of the hamate may be
approached through the carpal tunnel or Guyon’s
canal. However, the carpal tunnel approach has
the disadvantage of requiring release of the trans-
verse carpal ligament, which may prolong
recovery.
Technique
A longitudinal or slightly curvilinear 3- to 4-cm
incision is started at Kaplan’s line and is carried to
the level of the distal wrist crease. The incision
travels in the depression between the thenar and
hypothenar eminences, in line with the central axis
of the ring finger. The incision can be extended
proximally by coursing at a 45 angle to the distal
wrist crease, after which it can be extended more
proximally along the course of the ulnar artery or
by curving back radially (Fig. 23). After incising
the skin and subcutaneous fat and palmar fascia,
the transverse fibers of the flexor retinaculum
should become apparent. The palmaris longus (if
present) is moved radially to better expose the
flexor retinaculum and protect the palmar cutane-
ous branch of the median nerve. Gentle dissection
is then performed to identify the proximal and dis-
tal extent of the flexor retinaculum. The distal
border can be identified by looking for a fat
pad, which also demarcates the position of the
superficial palmar arch.
Proximally, the antebrachial fascia is recog-
nized as being very thin compared with the TCL.
This proximal fascia should be incised first, and
then the median nerve immediately identified. The
flexor retinaculum is then incised longitudinally
from proximal to distal, aiming at the long finger
along the ulnar border of the median nerve. Care
is taken not to encroach on the hook of the
hamate, which lies near the ulnar artery and
nerve. The median nerve and digital flexor
tendons lie immediately dorsal to the TCL and
may be retracted radially to gain limited access to
the carpus. The recurrent motor branch of the
median nerve should be identified before closure
and, if an extended radial incision is used, the
palmar cutaneous branch of the median nerve
should also be identified [12].
138 CARDOSO & SZABO

Fig. 22. Visualization of the volar scaphoid after incising radioscaphocapitate and trapezium scaphotrapezial ligaments.
(From Ruby LK. Arthrotomy. In: Cooney WP, Linscheid RL, Dobyns JH, editors. The wrist: diagnosis and operative
treatment. St. Louis (MO): Mosby; 1997; with permission.)

To access the hook of the hamate, the median

nerve and finger flexors are gently retracted
radially while the TLC is lifted ulnarly. The entire
hook of the hamate is accessible without excessive
dissection of the ulnar nerve or artery (Fig. 24).

Central palmar approach

This approach is an extension of the carpal
tunnel approach and provides access to the ulnar
aspect of the distal radius and the palmar portion
of the DRUJ, and better exposure to the volar
carpus (Fig. 25).

Fig. 23. Midpalmar approach. The incision stops at the
distal wrist crease for carpal tunnel approach. (From
Ruby LK. Arthrotomy. In: Cooney WP, Linscheid
RL, Dobyns JH, editors. The wrist: diagnosis and oper-
ative treatment. St. Louis (MO): Mosby; 1997; with
permission.)
Technique
The incision, starting at Kaplan’s line, is an
extension of the incision to expose the carpal
canal. The incision is carried proximally, crossing
the wrist crease in a curvilinear or oblique fashion.
The incision is continued longitudinally along the
ulnar border of the palmaris longus to avoid the
palmar cutaneous branch of the median nerve,
which lies just radial to it. The median nerve
should be identified as it travels beneath the
muscle belly of the middle-finger flexor digitorum
superficialis. The palmar cutaneous branch of the
median nerve should also be identified as it
 WRIST ANATOMY AND SURGICAL APPROACHES
Fig. 24. Carpal tunnel approach with access to the hook of the hamate. (From Ruby LK. Arthrotomy. In: Cooney WP,
Linscheid RL, Dobyns JH, editors. The wrist: diagnosis and operative treatment. St. Louis (MO): Mosby; 1997; with
permission.)
branches radially off the median between 4 and 8
cm proximal to the distal wrist crease. The
palmaris longus tendon is then freed from the
flexor retinaculum and moved radially. The flexor
retinaculum should be incised as discussed in the
carpal tunnel approach section. The median nerve
along with the digital flexors can then be retracted
ulnarly or radially to gain access to deeper struc-
tures in the wrist (Fig. 26). Immediately below
the digital flexors lies the pronator quadratus.
Just proximally, the anterior interosseous artery
and nerve are identified traveling along the inter-
osseous membrane before supplying the pronator
quadratus. Care is taken to visualize the ulnar ar-
tery, which lies between the flexor carpi ulnaris
and the flexor digitorum superficialis to the ring
and small fingers. The pronator quadratus may
be released either radially or ulnarly to access
the radius and the volar portion of the distal ra-
dioulnar joint (Figs. 27 and 28).
139
Approach to Guyon’s canal
Indications and landmarks
Fractures and nonunions of the pisiform and
hook of the hamate and injuries to the ulnar nerve
and artery may be addressed through this incision.
Landmarks include the flexor carpi ulnaris ten-
don, pisiform, and hook of the hamate.
Technique
An incision started just proximal to the wrist
crease is carried in a zigzag fashion distally
between the pisiform and hook of the hamate.
Blunt dissection through the subcutaneous tissues
is recommended to avoid injuring the palmar
cutaneous branches of the ulnar nerve that may
be encountered. Proximally, the flexor carpi
ulnaris is identified and retracted ulnarly to
expose the ulnar artery and nerve. The ulnar
nerve is traced from the palmar crease to the level
140 CARDOSO & SZABO

Fig. 25. The mid-palmar approach can be extended distally to release the median nerve from the carpal tunnel. Bottom
detail, at the level of the distal radius, the flexor tendons and the median nerve are retracted radially to expose the volar
medial distal radius. (From Fernandez DL, Jupiter JB. Fractures of the distal radius. New York: Springer; 1996. p. 67–
102; with permission.)

of Guyon’s canal. The palmaris brevis muscle is
seen and moved ulnarly. The volar carpal and
pisohamate ligaments are identified and divided.
The fibrous arch of the origin of the hypothenar
muscles is then encountered and incised to unroof
the ulnar nerve and artery. The pisiform and hook
of the hamate are easily palpable and can be
further exposed with subperiosteal elevation
(Fig. 29) [12].
is performed carefully as the superficial branches
of the radial nerve lie subcutaneous to the inci-
sion. Volar retraction of the extensor pollicis bre-
vis reveals the radial artery, which should be
gently swept volarly. The capsule may then be
incised longitudinally to expose the scaphoid (see
Fig. 30). Care should be taken to avoid stripping
the blood supply to the proximal pole of the
scaphoid, found at its dorsal ridge [13].

Radial approach to the scaphoid Longitudinal dorsal approach

Indications
The radial approach to the scaphoid allows
excellent visualization of the proximal pole of the
scaphoid and dorsal exposure for placing bone
graft. The incision may be extended proximally to
address fractures of the radial styloid. Landmarks
include the anatomic snuffbox formed by the
tendons of the first and third dorsal compart-
ments, and the tip of the radial styloid.
Technique
A curvilinear incision is made overlying the
anatomic snuffbox between the first and third
dorsal compartments (Fig. 30). Further dissection
Indications
The longitudinal dorsal approach has several
uses, including access to the dorsal aspect of the
distal radius, the radiocarpal and radioulnar
joints, the carpal bones, and the extensor tendons.
Landmarks include Lister’s tubercle, the lunate
fossa, the long-finger metacarpal, and the radial
and ulnar styloid. The extensor retinaculum may
be incised at different levels depending on the
required exposure. Access to the digital extensors
is through the fourth dorsal compartment,
whereas the DRUJ is visualized through the
fifth dorsal compartment. Access to most dorsal
structures of the dorsal wrist, including the distal
 WRIST ANATOMY AND SURGICAL APPROACHES 141

Fig. 26. Midpalmar approach. The medial nerve, flexor pollicis longus, and index profundus are retracted radially, and
the rest of the digital flexors are retracted ulnarly. (From Ruby LK. Arthrotomy. In: Cooney WP, Linscheid RL, Dobyns
JH, editors. The wrist: diagnosis and operative treatment. St. Louis (MO): Mosby; 1997; with permission.)

Fig. 27. Palmar capsule incisions: through the space of Poirier and between palmar radiocarpal ligaments. The pronator
quadratus is also elevated for further exposure. (From Ruby LK. Arthrotomy. In: Cooney WP, Linscheid RL, Dobyns
JH, editors. The wrist: diagnosis and operative treatment. St. Louis (MO): Mosby; 1997; with permission.)
142 CARDOSO & SZABO

Fig. 28. Radial retraction of the flexor tendons allows visualization of the ulnar aspect of the radius and the palmar
aspect of the DRUJ. (From Ruby LK. Arthrotomy. In: Cooney WP, Linscheid RL, Dobyns JH, editors. The wrist: di-
agnosis and operative treatment. St. Louis (MO): Mosby; 1997; with permission.)

Fig. 29. Approach to Guyon’s canal allows access to the pisiform and hook of the hamate. (From Ruby LK. Arthrot-
omy. In: Cooney WP, Linscheid RL, Dobyns JH, editors. The wrist: diagnosis and operative treatment. St. Louis (MO):
Mosby; 1997; with permission.)
 WRIST ANATOMY AND SURGICAL APPROACHES 143

Fig. 30. Dorsoradial approach to the scaphoid. (A) The incision (dashed line) exposes the scaphoid and bone graft donor
site. Subcutaneous tissues are raised from the extensor retinaculum, and the 1,2 ICSRA is identified. RA, radial artery; S,
scaphoid; R, radius. (B) Branches (I, II, III) of the superficial branch of the radial nerve (SBRN) are identified and pro-
tected. Dashed lines indicate incisions of the first and second extensor compartments. (From Shin AY, Bishop AT, Berg-
er RA. Vascularized pedicled bone graft for disorders of the carpus. Tech Hand Up Extrem Surg 1998;2(2):100; with
permission.)

Fig. 31. Standard dorsal approach. An incision is made inline with the index finger metacarpal. The capsule is ap-
proached between the third and fourth dorsal compartments. (From Szabo RM, Newland CC. Open reduction and lig-
amentous repair for acute lunate and perilunate dislocations. In: Gelberman RH, editor. Masters techniques in
orthopaedic surgery, the wrist. New York: Raven Press; 1994. p. 172; with permission.)
144 CARDOSO & SZABO

radius and mid-carpus, can be accessed between
the third and fourth dorsal compartments.
Technique
A longitudinal incision is made over the
dorsum of the wrist in line with the index-finger
metacarpal. Alternatively, a more centralized
incision in line with the long-finger metacarpal
may be used (Fig. 31). The incision starts at the
base of the carpometacarpal ligament and travels
just ulnar to Lister’s tubercle. The incision is car-
ried down to the level of the extensor retinaculum,
taking care to avoid injury to sensory nerves and
large dorsal veins. Skin flaps are made as thick
as possible because of the delicate nature of the
dorsal skin.
The extensor retinaculum is then visualized
and incised between the third and fourth dorsal
compartments. The extensor pollicis longus is
radially retracted from the groove formed by
Lister’s tubercle. The fourth compartment is
then elevated ulnarly, taking care to remain
subperiosteal to avoid tendon adhesions. Subper-
iosteal dissection is continued to expose the distal
radius and carpal capsule. The capsule is entered
by making a longitudinal incision in line with
Lister’s tubercle to the level of the capitate. The
capsule may then be subperiostially elevated to
visualize the carpus [14,15].
Dorsal approach to the distal radioulnar joint
This less-extensile approach is used if only
access to the DRUJ is required.
Technique
A longitudinal or zigzag skin incision is made
directly over the dorsal ulna in line with the ulnar
aspect of the ring-finger metacarpal (Fig. 32).
After skin flaps are raised, the fifth dorsal com-
partment is identified. The dorsal cutaneous
branch of the ulnar nerve should be identified

Fig. 32. Limited dorsal approach to the DRUJ. (From Ruby LK. Arthrotomy. In: Cooney WP, Linscheid RL, Dobyns
JH, editors. The wrist: diagnosis and operative treatment. St. Louis (MO): Mosby; 1997; with permission.)
 WRIST ANATOMY AND SURGICAL APPROACHES 145

and protected in the distal aspect of the incision.
A longitudinal incision through the extensor ret-
inaculum permits ulnar reflection of the extensor
carpi ulnaris and radial reflection of the extensor
digiti minimi (Fig. 33). The capsule of the distal
radioulnar joint, directly below the compart-
ment, can be entered through a longitudinal in-
cision. The ulnocarpal joint is visualized by
continuing the capsular incision distally to the lu-
notriquetral joint. Care must be taken to avoid
cutting the dorsal radioulnar ligament or TFC
(Fig. 34).
Direct ulnar approach
Indications and landmarks
The direct ulnar approach is useful for treat-
ment of distal ulnar styloid fractures, excision of
the distal ulna, exposure of the extensor carpi
ulnaris, and limited exposure of the TFCC.
Landmarks include the subcutaneous border
of the ulna, the extensor carpi ulnaris tendon, and
the ulnar styloid (if not displaced).
Technique
A longitudinal incision is made over the ulnar
aspect of the distal ulna. The incision is centered
just volar to the extensor carpi ulnaris tendon and
carried distally across the carpus. The dorsal
cutaneous branch of the ulnar nerve should be
localized as is crosses the ulna from volar to dorsal.
The nerve should be gently freed from the subcuta-
neous tissue and retracted volarly. The extensor
retinaculum should be incised over the extensor
carpi ulnaris and the tendon retracted dorsally.
The ulnar styloid and ulnocarpal joint should
now be apparent. To access the TFCC, a longitudi-
nal incision should be made through the capsule,
taking care not to injure the underlying TFCC.
Wound closure should include a careful repair of

Fig. 33. The extensor retinaculum is incised over the fifth dorsal compartment. (From Ruby LK. Arthrotomy. In: Coo-
ney WP, Linscheid RL, Dobyns JH, editors. The wrist: diagnosis and operative treatment. St. Louis (MO): Mosby; 1997;
with permission.)
146 CARDOSO & SZABO

Fig. 34. The DRUJ can be visualized by ulnar retraction of the extensor digiti minimi. Care is taken to avoid incising the
TFCC. The TFC and dorsal radiotriquetral ligament may be visualized by incision of the dorsal ulnar wrist capsule.
(From Ruby LK. Arthrotomy. In: Cooney WP, Linscheid RL, Dobyns JH, editors. The wrist: diagnosis and operative
treatment. St. Louis (MO): Mosby; 1997; with permission.)

the extensor retinaculum over the extensor carpi
ulnaris to prevent tendon subluxation [13].
Application of an external fixator
Indications
An external fixator is indicated for stabilizing
distal radius fractures, radiocarpal dislocations,
and carpal injuries.
Technique
Typically two pins are applied to the dorsor-
adial aspect of the index finger metacarpal,
followed by two pins to the dorsoradial aspect
of the radial shaft. Percutaneous placement is not
recommended because of the proximity of the
superficial branch of the radial nerve and lateral
antibrachial cutaneous nerve. The metacarpal
incisions are made first to ensure adequate fixator
length.
Either one or two incisions are made over the
dorsoradial aspect of the index finger metacarpal.
If two incisions are used, the distal one overlies
the midshaft of the metacarpal, whereas the
proximal one lies at its base. Subcutaneously,
sensory branches of the radial nerve may be
encountered and retracted away. The dissection
is then carried to bone. The metacarpophalangeal
joint should be held in flexion to slide the lateral
band and first dorsal interosseous aponeurosis
distally and away from the site of pin insertion.
For the proximal pins, a reduction should be
attempted before the site of incision is planned
to decrease the chance of excessive skin ten-
sion when the external fixator is finally applied.
A longitudinal incision is conventionally made
on the dorsoradial aspect of the radial shaft,
approximately 10 cm proximal to the radial
styloid. Alternatively, the incision may be planned
5 cm proximal to the fracture. Subcutaneously,
 WRIST ANATOMY AND SURGICAL APPROACHES 147

Fig. 35. The partially threaded pins for the external fixation device are inserted in the interval between the extensor carpi
radialis longus (ECRL) and the extensor carpi radialis brevis (ECRB) to protect the sensory branch of the radial nerve.
MC II, second metacarpal. (From Trumble TE, Culp R, Hanel DP, et al. Intra-articular fractures of the distal aspect of
the radius. Bone Joint Surg Am 1998;80:582–600; reprinted with permission from The Journal of Bone and Joint
Surgery, Inc.)

branches of the lateral antebrachial cutaneous
nerve may be identified and protected. The
brachioradialis tendon and extensor carpi radialis
longus are next encountered. The latter is distin-
guished by noting tendon excursion with wrist
flexion and extension. The space between the
brachioradialis and extensor carpi radialis longus
is developed by first opening the overlying fascial
sheath. As the dissection is carried deeper, the
radial sensory nerve should be identified and
protected as it exits between the brachioradialis
tendon and the extensor carpi radialis longus. The
interval is carried down to the level of the radius,
where the half pins are placed under direct
visualization.
Some authors advocate placing pins in the
interval between the extensor carpi radialis longus
and brevis. Placement in this interval reduces
contact with the radial sensory nerve. Further-
more, with the wrist immobilized, excursion
between the extensor carpi radialis longus and
brevis tendons is eliminated, thus alleviating soft
tissue motion about the pins (Fig. 35) [4].
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[3] Kaplan EB. Guide lines to deep structures and dy-
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[4] Trumble TE, Culp R, Hanel DP, et al. Instructional
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[5] Szabo RM. Distal radioulnar joint instability. J
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